Sodium Polystyrene Sulfonate (sodium polystyrene sulfonate)

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There are no contraindication interactions for this drug.

Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

Bile Acid Sequestrants And Ion Exchange Resins/Tiratricol

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Bile acid sequestrants and ion exchange resins may decrease the gastrointestinal absorption of tiratricol.(1,2)

CLINICAL EFFECTS: Simultaneous administration of a bile acid sequestrants and ion exchange resins may result in decreased absorption and effectiveness of tiratricol.(1,2)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The US manufacturer of tiratricol states concurrent use of bile acid sequestrants and ion exchange resins with tiratricol should be avoided.(1) The UK manufacturer of tiratricol states use of antacids, charcoal, calcium, cationic resins (e.g. cholestyramine), iron, sucralfate, and other gastrointestinal agents may interfere with the gastrointestinal absorption of tiratricol should be taken before or after tiratricol (more than 2 hours before or after if possible). For cholestyramine, tiratricol should be taken 1 hour before or 4 hours after the resin dose. Adjustment of the tiratricol dose may be required to obtain the desired effect.(2)

DISCUSSION: Bile acid sequestrants and ion exchange resins decrease thyroid hormone exposure by binding and delaying or preventing absorption.(1,2)

Polystyrene Sulfonate/Sorbitol

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Sorbitol may damage the intestinal mucosa, trigger vasospasms in the intestinal vasculature, and increase inflammation.(1) Polystyrene sulfonate crystals may deposit in these areas, resulting in further damage.(2,3)

CLINICAL EFFECTS: Concurrent use of sorbitol and polystyrene sulfonate (either orally or rectally) may result in colonic necrosis, bleeding, ischemic colitis, and perforation of the gastrointestinal tract. Fatalities have been reported.(4)

PREDISPOSING FACTORS: Predisposing factors may include a history of intestinal disease or surgery, hypovolemia, and/or renal insufficiency/failure. Premature infants may also be predisposed to the interaction.(4)

PATIENT MANAGEMENT: The US manufacturer of sodium polystyrene sulfonate states that concurrent use with sorbitol (either orally or rectally) is not recommended.(4) In the event that sorbitol is used as a vehicle to administer polystyrene sulfonate rectally as an enema, particular attention should be given to administering a cleansing enema following the completion of the sodium polystyrene sulfonate enema.(4) Patients who have received concurrent polystyrene sulfonate and sorbitol should be monitored for signs of gastrointestinal complications and instructed to report abdominal pain and/or signs of gastrointestinal bleeding. If concurrent therapy is warranted, monitor patients receiving concurrent therapy for signs of blood loss, including decreased hemoglobin, hematocrit, fecal occult blood, and/or decreased blood pressure and promptly evaluate patients with any symptoms. When applicable, perform agent-specific laboratory test (e.g. INR, aPTT) to monitor efficacy and safety of anticoagulation. Discontinue anticoagulation in patients with active pathologic bleeding. Instruct patients to report any signs and symptoms of bleeding, such as unusual bleeding from the gums or nose; unusual bruising; red or black, tarry stools; red, pink or dark brown urine; acute abdominal or joint pain and/or swelling.

DISCUSSION: There have been numerous case reports of intestinal necrosis following the use of sodium polystyrene sulfonate and sorbitol.(1,5-13) In the majority of these cases, sorbitol was used as a vehicle for rectal administration of sodium polystyrene sulfonate(5-10); however, there have also been reports with oral administration (1,11,12) and in patients who received both oral and rectal sodium polystyrene with sorbitol.(13,14) Fatalities have been reported.(1,5,6)

Potassium Binders/Potassium Supplements

SEVERITY LEVEL: 2-Severe Interaction: Action is required to reduce the risk of severe adverse interaction.

MECHANISM OF ACTION: Patiromer, sodium polystyrene sulfonate and sodium zirconium cyclosilicate bind to potassium.(1-3)

CLINICAL EFFECTS: Concurrent use of potassium supplements and patiromer, sodium polystyrene sulfonate or sodium zirconium cyclosilicate may decrease the effectiveness of both agents.

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: Patients should normally not receive potassium supplements and patiromer, sodium polystyrene sulfonate or sodium zirconium cyclosilicate concurrently.(1-3) Patiromer, sodium polystyrene sulfonate or sodium zirconium cyclosilicate are indicated for management of hyperkalemia. Consider discontinuing or holding potassium supplements in patients who develop hyperkalemia requiring treatment.

DISCUSSION: Patiromer, sodium polystyrene sulfonate and sodium zirconium cyclosilicate are indicated for hyperkalemia. Consider discontinuing or holding potassium supplements in patients receiving sodium polystyrene sulfonate or sodium zirconium cyclosilicate.

Moderate Interaction: Assess the risk to the patient and take action as needed.

Polystyrene Sulfonate/Lithium

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Polystyrene sulfonate may bind and delay or prevent the absorption of lithium from the gastrointestinal tract.(1)

CLINICAL EFFECTS: Simultaneous administration of polystyrene sulfonate may result in decreased levels of and effectiveness from lithium.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The US manufacturer of sodium polystyrene sulfonate states that oral medications should be administered at least 3 hours apart from polystyrene sulfonate. Patients with gastroparesis may require a 6 hour separation. If concurrent therapy is warranted, consider monitoring lithium levels and clinical response.(1)

DISCUSSION: Because polystyrene sulfonate may bind and delay or prevent the absorption of lithium from the gastrointestinal tract, the US manufacturer of sodium polystyrene sulfonate states that lithium should be administered at least 3 hours apart from polystyrene sulfonate.(1)

Polystyrene Sulfonate/Slt Cation-Donating Antacids

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Polystyrene sulfonate may bind the cation from the antacid, resulting in increased intestinal absorption of non-neutralized bicarbonate, which may result in systemic alkalosis and decreased potassium binding by polystyrene sulfonate. Intestinal obstruction has occurred with aluminum hydroxide because of concretion.

CLINICAL EFFECTS: Simultaneous oral use may result in metabolic alkalosis and a decrease in the potassium lowering effect of polystyrene sulfonate. Intestinal obstruction has been reported with aluminum hydroxide.

PREDISPOSING FACTORS: Patients with renal failure may be at a higher risk of systemic alkalosis.

PATIENT MANAGEMENT: Consider the use of alternative agents to cation-donating antacids in patients receiving oral polystyrene sulfonate when possible. If concurrent use is required, separate the dosing by several hours.(1) Some vitamin preparations may contain sufficient quantities of calcium and/or magnesium salts with antacid properties to interact as well.

DISCUSSION: In a study in 11 patients with decreased renal function, the administration of magnesium hydroxide and sodium polystyrene sulfonate produced moderate to moderately severe metabolic alkalosis.(2) There are case reports documenting this affect as well.(3-7) Intestinal obstruction has been reported with aluminum hydroxide and sodium polystyrene sulfonate.(8) If the polystyrene sulfonate is administered rectally, a clinically significant interaction is not likely to occur.

Polystyrene Sulfonate/Thyroid Preparations

SEVERITY LEVEL: 3-Moderate Interaction: Assess the risk to the patient and take action as needed.

MECHANISM OF ACTION: Polystyrene sulfonate may bind and delay or prevent the absorption of thyroid preparations from the gastrointestinal tract.(1)

CLINICAL EFFECTS: Simultaneous administration of polystyrene sulfonate may result in decreased levels of and effectiveness from thyroid preparations.(1)

PREDISPOSING FACTORS: None determined.

PATIENT MANAGEMENT: The US manufacturer of levothyroxine states that levothyroxine should be administered at least 4 hours apart from polystyrene sulfonate.(1)

DISCUSSION: Because polystyrene sulfonate may bind and delay or prevent the absorption of levothyroxine from the gastrointestinal tract, the US manufacturer of levothyroxine states that levothyroxine should be administered at least 4 hours apart from polystyrene sulfonate.(1)

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• Chronic idiopathic constipation
• Colonic necrosis
• Fecal impaction
• Gastrointestinal hypomotility
• Gastrointestinal obstruction
• Hypokalemia
• Ileus
• Inflammatory bowel disease
• Ischemic colitis

• Absence of bowel sounds
• Alkalosis
• Gastrointestinal hemorrhage
• Gastrointestinal tract surgery
• Prolonged QT interval

• Cardiac arrhythmia
• Edema
• Hypocalcemia
• Hypomagnesemia
• Hypovolemia
• Kidney disease with reduction in glomerular filtration rate (GFr)
• Severe chronic heart failure
• Severe uncontrolled hypertension

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Less Frequent

• Fecal impaction
• Hypocalcemia
• Hypokalemia

Rare or Very Rare

• Alkalosis
• Bronchitis
• Gastrointestinal concretion
• Gastrointestinal hemorrhage
• Gastrointestinal perforation
• Gastrointestinal ulcer
• Intestinal ischemic necrosis
• Ischemic colitis

More Frequent

• Anorexia
• Constipation
• Nausea
• Vomiting

Rare or Very Rare

• Diarrhea

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